African Journal of Oral Health
Volume 1 Number 1 2004: 2-16
This paper was first published in Developing Dentistry 2004; 5: 9-20Improvement of oral health in Africa in the 21st century - the role of the WHO Global Oral Health Programme
Poul Erik Petersen
World Health Organization, Oral Health Programme, Geneva, Switzerland
Summary
Chronic diseases and injuries are overtaking communicable diseases as the leading health problems in all but a few parts of the world. This rapidly changing global disease pattern is closely linked to changing lifestyles which include diet rich in sugars, widespread use of tobacco and increased consumption of alcohol. These lifestyle factors also significantly impact oral health, and oral diseases qualify as major public health problems owing to their high prevalence and incidence in all regions of the world. Like all diseases, they affect primarily the disadvantaged and socially marginalized populations, causing severe pain and suffering, impairing functionability and impacting quality of life. Traditional treatment of oral diseases is extremely costly even in industrialized countries and is unaffordable in most low and middle-income countries. The WHO Global Strategy for prevention and control of noncommunicable diseases and the ”common risk factor approach” offer new ways of managing the prevention and control of oral diseases. This report outlines major characteristics of the current oral health situation in Africa and development trends as well as WHO strategies and approaches for better oral health in the 21st century.Key words: Africa, oral health, risk factor, development
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Http:// www.ajoh.org © African Journal of Oral Health.
African Journal of Oral Health
Volume 1 Number 1 2004: 2-16
THE BURDEN OF ORAL DISEASE
Despite vast improvement in global oral health, problems still persist in many communities and populations around the world - particularly among the underprivileged in both developed and developing countries.
Correspondence: Dr Poul Erik Petersen
World Health Organization, Oral Health Programme, Chronic Disease and Health Promotion, 20 Avenue Appia, 1211 Geneva 27,
Switzerland.
The distribution and severity of oral diseases vary in different parts of the world and within the same country or region. Several oral epidemiological studies have been carried out applying WHO methodology and criteria1. Currently, the dental caries level is high in several American and European countries, while it appears less severe in most African countries. Figure 1 highlights the dental caries experience among 12-year-old children according to the six WHO regional offices in the year
20002,3, based on the DMFT (Decayed, Missing and Filled Teeth index.
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Oral health in Africa – PE Petersen African Journal of Oral Health
Volume 1 Number 1 2004: 1-15
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Http:// www.ajoh.org © African Journal of Oral Health.
Oral health in Africa – PE Petersen African Journal of Oral Health
Volume 1 Number 1 2004: 1-15
Figure 1 Dental caries experience (DMFT) of 12-year-old children according to WHO regional offices (Source: WHO Global Oral Health Data Bank and WHO Oral Health Country/Area Profile Programme, 2000)2,3
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Http:// www.ajoh.org © African Journal of Oral Health.
Oral health in Africa – PE Petersen African Journal of Oral Health
Volume 1 Number 1 2004: 1-15
Figures 2-3 outline the current levels of dental caries in 12-year-olds and 35-44 year olds in Africa. However, the incidence of dental caries is predicted to increase in several developing countries in the region, particularly as a result of a growing consumption of sugars and inadequate exposure to fluorides.
In many African countries, access to oral health services is limited and teeth are often left untreated or are extracted to relieve pain or discomfort. This is reflected in the components of the DMFT index as shown for some AFRO countries4-7 in Figure 4. Losing teeth is still seen by many as a natural consequence of ageing. Some countries have in recent years experienced an increase in tooth loss among adults in Africa, the proportion of edentulous adults aged 65 years varies from 6% in Gambia2 to 25% in Madagascar4.
Figure 2. Dental caries levels (DMFT) of 12-year-olds in Africa2,3
Figure 3 Dental caries levels (DMFT) of 35-44-year-olds in Africa2,3
Globally, most children have signs of gingivitis and, among adults, the initial stages of periodontal diseases are prevalent. Severe periodontitis, which may cause tooth loss, is found in 5-15% of most populations. The periodontal conditions of populations surveyed recently in some African countries4-7 are highlighted in Figure 5; the surveys used the so-called Community Periodontal Index1.
The prevalence of oral cancer is particularly high among the male population, and is the eighth most common cancer worldwide8. Figure 6 shows the figures available on oral cancer in Africa related to the oral cavity. The high incidence rates relate directly to risk behaviours such as smoking, use of smokeless tobacco and alcohol consumption. In Africa the prevalence of smoking is particularly high in men and varies from 15% of adults in Nigeria to 67% in Kenya9.
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Http:// www.ajoh.org © African Journal of Oral Health.
Oral health in Africa – PE Petersen African Journal of Oral Health
Volume 1 Number 1 2004: 1-15
Figure 4 Dental caries experience (DMFT) of 12-year-olds in selected AFRO countries4-7
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Http:// www.ajoh.org © African Journal of Oral Health.
Oral health in Africa – PE Petersen African Journal of Oral Health
Volume 1 Number 1 2004: 1-15
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Http:// www.ajoh.org © African Journal of Oral Health.
Oral health in Africa – PE Petersen African Journal of Oral Health
Volume 1 Number 1 2004: 1-15
Figure 5 Mean percentages of 35-44-year-olds by maximum Community Periodontal Index scores in selected AFRO countries4-7
Figure 6 The incidence of cancer in countries of sub-Saharan Africa in 2000 (Source: WHO International Agency for Research on Cancer, 2003) 8
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Http:// www.ajoh.org © African Journal of Oral Health.
Oral health in Africa – PE Petersen African Journal of Oral Health
Volume 1 Number 1 2004: 1-15
Qat is a leafy narcotic substance popular in several countries in East Africa and the Arabian Peninsula. It can be consumed in the form of tea or smoked like tobacco, although the most common mode of ingestion is by chewing the fresh leaves. Consumption of qat can lead to adverse oral effects including oral mucosal lesions, dryness of the mouth, discoloration of teeth and periodontal problems.
The regions of the world have different oral health profiles. In addition to oral precancer and oral cancer, countries in Africa must urgently address a number of very serious oral conditions including noma (cancrum oris), ANUG (acute necrotizing ulcerative gingivitis), and oral manifestations of HIV/AIDS. Analyses have shown that oral manifestations of this disease often include candida infections, hairy leukoplakia, oral ulcers and gingival bleeding, necrotizing periodontitis, leukoplakia and Kaposi’s sarcoma3.
Most – particularly developing – countries still lack reliable data on the frequency and severity of oro-dental trauma10. Some countries report dental trauma in about 10-15% of children, and a significant proportion of dental trauma derives from road accidents or violence and unsafe playgrounds or schools. In industrialized countries, the costs of immediate and follow-up care for dental trauma patients are high, while such information is not available in developing countries of Africa.
Diagnosis and treatment of craniofacial anomalies such as cleft lip and palate present a number of challenges to public health. Oro-facial clefts occur in around 1 per 500-700 births, the rate varying substantially across ethnic groups and geographical areas11 and appear to be environment-related, a higher risk being associated with the mother’s use of tobacco and alcohol and her nutritional level. There are many parts of the world, in particular parts of Africa for which there is little or no information available on the frequency of craniofacial anomalies. There is to date no consistent evidence of trends over time, nor is there consistent variation by socioeconomic status, but these aspects have not yet been adequately studied. Other conditions that may lead to special health care needs include Down’s syndrome, cerebral palsy, learning and developmental disabilities, and genetic and hereditary disorders with oro-facial defects.
Oral disease burdens and common risk factors
Given their prevalence worldwide, oral diseases are major public health problems. Their impact on individuals and communities in terms of pain and suffering, functional impairment and reduced quality of life is considerable, and they are the fourth most expensive to treat in most industrialized countries. Were it available in many low-income countries, treatment of dental caries in children alone would exceed the total child health care budget.
A core group of modifiable risk factors is common to many chronic diseases and injuries. The four most prominent NCDs - cardiovascular diseases, diabetes, cancer and chronic obstructive pulmonary diseases - share common risk factors with oral diseases that are lifestyle-related and preventable. The greatest burden of all diseases is on the disadvantaged and socially marginalized. A major benefit of the common risk factor approach is the focus on improving health conditions for the whole population as well as for high risk groups, thereby reducing inequities. The WHO Global Strategy for the prevention and control of noncommunicable diseases represents a new approach to managing the prevention and control of oral diseases.
WHO STRATEGIES AND APPROACHES IN ORAL DISEASE PREVENTION AND HEALTH PROMOTION
WHO's goals are to build healthy populations and communities and to combat ill-health. Four strategic directions provide the broad framework for WHO's technical work and in relation to oral health.
1. Reducing the burden of oral disease and disability, especially in poor and marginalized populations.
2. Promoting healthy lifestyles and reducing risk factors to oral health that arise from environmental, economic, social and behavioural causes.
3. Developing oral health systems that equitably improve oral health outcomes, respond to people's legitimate demands, and are financially fair.
4. Framing policies in oral health, based on integration of oral health into national and community health programmes, and promoting oral health as an effective dimension for development policy of society.
The threat posed by noncommunicable diseases and the need to provide urgent and effective public health responses led to the formulation of a global strategy for prevention and control of these diseases, endorsed in 2000 by the 53rd World Health Assembly (resolution WHA 53.17). Priority is given to diseases – including oral diseases – which are linked by common, preventable and lifestyle related risk factors (e.g. unhealthy diet, tobacco use).
As emphasized in the World Oral Health Report 200312, the high relative risk of oral disease relates to sociocultural determinants such as poor living conditions, poor access to safe water or sanitary facilities, low education levels, and lack of traditions, beliefs and culture in support of oral health. Communities and countries with inappropriate exposure to fluorides also have a higher risk of dental caries. Control of oral disease depends on the availability and accessibility of oral health systems but risk reduction is only possible if services are oriented towards primary health care and prevention. In addition to the distal sociocultural and environmental factors, the model emphasizes the role of intermediate, modifiable risk behaviours, i.e. oral hygiene practices, sugars consumption (amount, frequency of intake, types) as well as tobacco use and excessive alcohol consumption.
Clinical and public health research has shown that individual, professional and community measures are effective in preventing most oral diseases13. However, optimal intervention in relation to oral disease is not universally available or affordable because of escalating costs and limited resources. This, together with insufficient focus on primary prevention of oral diseases, poses a considerable challenge particularly for developing countries of Africa, and where populations for the most part are underserved. In several African developing countries the most important challenge is to offer essential oral health care within the context of primary health care programmes. Such programmes should meet the basic health needs of the population, strengthen active outreach to the community, organize primary care, and ensure effective patient referral.
The major challenges of the future will be to translate knowledge and experiences of disease prevention into action programmes. The development of such programmes is particularly difficult if oral health care is not fully integrated into national or community health programmes.
Health promotion and oral health
Health promotion deals with the broader determinants of health and seeks to reduce risks through sensitive policies and actions. Promotion of health in the settings where people live, work, learn and play is clearly the most creative and cost-effective way of improving oral health and, in turn, quality of life. Increasing urbanization as well as demographic and socio-environmental changes require comprehensive oral health action. It is unlikely that improvements in oral health can be achieved by isolated interventions that target specific behaviours. The most effective, sustainable interventions combine social policy and individual action through which healthy living conditions and lifestyles are promoted.
The WHO Global Oral Health Programme provides technical and policy support needed to enable countries to integrate oral health promotion with general health promotion. The development of programmes for oral health in targeted countries focuses on:
* Identification of health determinants; mechanisms in place to improve capacity to design and implement interventions that promote oral health.
* Implementation of community-based demonstration projects for oral health promotion, with special reference to poor and disadvantaged population groups.
* Building capacity in planning and evaluation of national programmes for oral health promotion and evaluation of oral health promotion interventions in operation.
* Development of methods and tools to analyse the processes and outcomes of oral health promotion interventions as part of national health programmes.
* Establishment of networks and alliances to strengthen national and international actions for oral health promotion.
In accordance with WHO overall priorities, the Global Oral Health Programme has adopted the following strategic orientations and priorities for action.
PRIORITY ACTION AREAS FOR GLOBAL ORAL HEALTH
Oral health and fluorides
Fluoride is being widely used on a global scale, with much benefit. Millions of people worldwide use fluoridated toothpaste, and/or are exposed to fluoridated water or fluoridated salt or other forms of fluoride applications (clinical topical fluorides, mouthrinses, tablets/drops). However, populations in many developing countries do not have access to fluorides for practical or